Abstract

Background There is a dearth of research into the mental health of
gay men, lesbians and bisexual men and women in the UK.

Aims To assess rates and possible predictors of mental illness in
these groups.

Method A comprehensive assessment was made of the psychological and
social well-being of a sample of gay men, lesbians and bisexual men and women,
identified using ‘snowball’ sampling.

Results Of the 1285 gay, lesbian and bisexual respondents who took
part, 556 (43%) had mental disorder as defined by the revised Clinical
Interview Schedule (CIS - R). Out of the whole sample, 361 (31%) had attempted
suicide. This was associated with markers of discrimination such as recent
physical attack (OR=1.7, 95% CI 1.3-2.3) and school bullying (OR=1.4, 95% CI
1.1-2.0), but not with higher scores on the CIS-R.

Conclusions Gay, lesbian and bisexual men and women have high levels
of mental disorder, possibly linked with discrimination.

Approximately 5% of the British population is predominantly or exclusively
gay or lesbian (Johnson et al,
2001). There has been much speculation but little evidence about
the psychological well-being of the gay male, lesbian and bisexual population
of Britain. Studies from North America, often based on community samples,
suggest that gay men and lesbians are more vulnerable to anxiety, depression,
deliberate self-harm and substance misuse than heterosexuals
(Hershberger & D'Augelli,
1995; Fergusson et al,
1999; Lock & Steiner,
1999; Cochran et al,
2003). However, to date most studies have used convenience
sampling, which will identify relatively small numbers of lesbians and gay men
and risks skewing the sample because of response bias. Very few studies have
addressed the psychological health of bisexual individuals. We have previously
reported a national controlled cross-sectional survey of sexuality and
psychological well-being in a UK-based population using a ‘
snowball’ sampling technique
(King et al, 2003),
which found that gay men and lesbians living in England and Wales were at
moderately increased risk of mental disorder and deliberate self-harm compared
with heterosexual men and women. We therefore set out to identify rates and
possible predictors of mental disorder and deliberate self-harm in individuals
who class themselves as exclusively gay or lesbian compared with those who
regard themselves as bisexual, and to explore the utility of the gay/lesbian
v. bisexual paradigm.

METHOD

Between September 2000 and July 2002 we undertook a cross-sectional survey
of 2430 gay, lesbian, bisexual, transgendered and heterosexual people over the
age of 16 years in England and Wales using ‘snowball’ sampling
(Gilbert, 1993). The method of
approaching first-wave participants was informed by a pilot study of
snowballing technique among older gay men and lesbians
(Warner et al, 2003).
First-wave participants were recruited from a variety of sources by means of
advertisements in the national, local and gay press, placing posters in public
libraries, advertising on gay and lesbian websites and leaving postcards in
gay venues. All participants were asked to help identify further recruits
(second and subsequent snowball waves). The snowball method is described in
detail elsewhere (King et al,
2003). The inclusion factors for this study were being aged 16
years or over and living in England or Wales. Participants remained anonymous.
Written informed consent was obtained prior to participation. This study had
the approval of the local research ethics committee.

Each participant was asked to complete a computer-based questionnaire
investigating a variety of health and social outcomes. The main outcome was
assessment of mental health status using the revised Clinical Interview
Schedule (CIS–R) with a case threshold of 11/12
(Lewis et al, 1988).
The CIS–R assesses the presence and severity of somatic complaints
associated with low mood or anxiety, fatigue, problems with memory and/or
concentration, sleep disturbance, irritability, worry about physical health,
depressed mood, depressive thoughts, non-healthrelated worry, generalised
anxiety, phobic anxiety, panic attacks, compulsive behaviours and obsessional
thoughts in the week prior to interview. Higher scores indicate greater
morbidity. Respondents also completed the 12-item General Health Questionnaire
(GHQ–12; Goldberg & Williams,
1988), a brief screening instrument with a maximum score of 12 and
threshold of 3/4 for significant psychological distress, and the 12-item Short
Form measure of quality of life (SF–12;
Ware et al, 1996), in
which higher scores indicate poorer quality of life. We also asked about
previous actual and considered deliberate self-harm, specifically ‘Have
you ever thought seriously about harming or killing yourself?’ and ‘
Have you ever actually harmed yourself (e.g. taking pills, cutting your
wrists)?’ In addition we sought demographic details and lifestyle
factors, including:

home and social life: length of residence and details of cohabitees;

use of illicit drugs and alcohol, including completion of the Alcohol Use
Disorders Identification Test (AUDIT;
Barbor et al, 1989) (a
score of over 8 indicates hazardous drinking);

Participants were asked to complete a series of questions about their
sexual orientation, practices, fantasy, emotional and social preference. For
the purpose of analysis, we used participants' categorical definition of their
sexuality (gay, lesbian or bisexual).

Statistics and analysis

Data were analysed using the Statistical Package for the Social Sciences
version 10.0. With the exception of logistic regression, data on men and women
were analysed separately. Univariate analyses were conducted using the
chi-squared test for categorical data and unpaired t-tests for
normally distributed, continuous data. Associations between binary dependent
variables and possible predictors were investigated using logistic regression.
Multivariable logistic regression with backward elimination (using the
likelihood ratio χ2) was used to identify variables that were
significantly independently associated with outcomes of interest. Variables
with more than 10% missing data were not included, to preserve power.
Variables used (dichotomised to yes/no unless otherwise stated) were gender
(male, female); sexuality (gay/lesbian or bisexual); age (dichotomised above
and below 40 years); employment status (employed, unemployed, retired,
student); ethnicity (White, Black, Asian); marital status (never married,
married at some point); number of children; living circumstances (alone or
sharing); mother's awareness of sexuality; father's awareness of sexuality;
conflict between sexuality and religion (none, some, considerable); nature of
current relationship (none, living together, living apart); experience of
recent personal attack; experience of recent damage to property; experience of
being insulted in the past 5 years; experience of being insulted at school;
experience of being bullied at school; use of drugs; HIV tested; and
discussion with general practitioner of emotional problems. Initial models
were fitted including all variables listed above. Non-significant variables
were removed and the model refitted to estimate odds ratios with 95%
confidence intervals.

RESULTS

Demographic findings

In total 741 men (656 gay, 85 bisexual) and 544 women (430 lesbian and 114
bisexual) took part in this survey. The results of the heterosexual sample
(n=1093) have been reported by King et al
(2003). The results of 13
transgendered respondents are not reported because of the small sample size.
Because there is no information about the size or characteristics of the
denominator population from which the sample is drawn in surveys using
snowball sampling, response rates cannot be reported. Demographic and
recruitment details are provided in Table
1.

There was no significant difference between first-wave participants and
subsequent ‘snowballed’ recruits in ethnicity, employment status,
social class, marital status, number of children or caseness on GHQ–12
and CIS–R. First-wave male recruits were more likely to be older than
snowballed participants (difference in mean ages 3.3 years, 95% CI
1.3–5.3). Compared with respondents over 40 years old, younger men were
more likely to be open about their sexuality with their mothers (OR=2.3, 95%
CI 1.6–3.2) and fathers (OR=2.1, 95% CI 1.5–2.9). Younger and
older men were equally likely to be open with siblings and work colleagues. No
age difference in these factors was apparent among female respondents.

Validity of definition of sexuality

We attempted to validate categorical selfdefinition of sexuality as gay
male/female or bisexual male/female by seeking information on other indicators
of sexual orientation (Table
2). Compared with bisexual men and women, gay men and lesbians had
significantly higher levels of same-sex attraction, fantasy and sexual
experience and were more comfortable with their sexuality. Gay men in
particular were more likely to have recognised their sexuality earlier in
their lives than bisexual men: 26% of gay men reported being aware of their
sexual orientation by the age of 10 years, compared with 8% of bisexual men
(P<0.001).

Comparison of stated sexuality with other measures of sexual
orientation1

Experience of discrimination

Of the 1249 respondents to questions on experience of acts of hostility or
discrimination, 1039 (83%) reported having experienced at least one of the
following: damage to property, personal attacks or verbal insults in the past
5 years or insults or bullying at school
(Table 3). Six hundred and
ninety (66%) respondents who had experienced discrimination attributed this to
their sexuality. Men and women who were bisexual had experienced similar
levels of verbal insults, property damage and bullying to those reported by
gay and lesbian respondents, but the latter group were more likely than the
bisexual respondents to attribute these attacks or insults to their sexuality
(χ2=22.5, d.f.=2, P<0.0001). Respondents under 40
years old were more likely to be subject to physical attacks (OR=1.9, 95% CI
1.5–2.5) and verbal insults (OR=1.6, 95% CI 1.2–2.0) than older
respondents. Compared with women, men were more likely to have been attacked
recently (OR=1.4, 95% 1.2–1.8) and to have experienced bullying at
school (OR=2.3, 95% CI 1.8–2.9).

Use of alcohol and drugs

Lifetime use of drugs, smoking and hazardous drinking (AUDIT score 8 or
over) were similar for men and women, and for bisexual men and women compared
with gay men and lesbians (Table
4). Men under 40 years old were at greater risk of exceeding the
AUDIT threshold score compared with older men (OR=1.3, 95% CI 1.1–1.6),
as were younger women compared with older women (OR=2.1, 95% CI
1.5–2.9). Gay men were more likely than bisexual men to have used drugs
in the month prior to the survey (see Table
3).

Comparison of rates of mental disorder, considered and attempted
suicide, and hazardous drinking

Psychological health and quality of life

Bisexual men scored significantly higher than gay men on the CIS–R
(mean scores 14.9 and 12.2, respectively; difference -2.7, 95% CI -5.3 to
-0.2, P=0.04), whereas there was no significant difference in mean
CIS–R scores between lesbians and bisexual women (mean scores 12.7 and
12.6, respectively). There was no statistically significant difference in mean
GHQ–12 scores: gay men and bisexual men scored 3.2 and 4.0 respectively;
lesbians and bisexual women 3.5 and 3.6. There was no difference in
SF–12 scores between gay men and bisexual men (mean difference -0.1, 95%
CI -2.2 to 2.0) or between lesbians and bisexual women (-1.0, 95% CI -3.2 to
1.2). Further data on mental health outcomes are provided in
Table 4. When CIS–R
scores were dichotomised with the usual threshold of 11/12, there was no
significant difference between gay and bisexual men or between lesbian and
bisexual women. Variables independently associated with scoring over the 11/12
threshold on the CIS–R were unemployment (OR=2.5, 95% CI 1.8–3.5);
being under 40 years old (OR=1.4, 95% CI 1.1–2.0); reporting conflict
between religious beliefs and sexuality (OR=2.2, 95% CI 1.5–3.3); being
attacked in the past 5 years (OR=1.5, 95% CI 1.1–1.9); being insulted in
the past 5 years (OR=1.7, 95% CI 1.3–2.2) and having been insulted at
school (OR=1.4, 95% CI 1.1–1.8). No factor emerged as being
significantly associated with case-defining GHQ–12 scores.

A relatively large proportion of respondents had considered or attempted
suicide (Table 4). Variables
independently associated with having considered suicide were age under 40
years (OR=1.4, 95% CI 1.1–2.0); being unemployed (OR=1.8, 95% CI
1.2–2.5) or a student (OR=1.7, 95% CI 1.1–2.5); or being attacked
in the past 5 years (OR=1.7, 95% CI 1.3–2.3). Black respondents were
less likely to have considered suicide (Black 8/31, White 630/ 1180; χ
2=9.5, d.f.=2, P=0.009). Variables associated with
attempted suicide were being female (OR=1.7, 95% CI 1.2–2.5), having
been attacked in the past 5 years (OR=1.4, 95% CI 1.1–1.9) and having
been insulted at school (OR=1.4, 95% CI 1.1–2.0).

DISCUSSION

Principal findings

This is the first large, UK-based comprehensive survey of psychological
well-being among gay men, lesbians and bisexual men and women. We found high
rates of planned and actual deliberate self-harm and high levels of
psychiatric morbidity as defined by CIS–R score among gay men (42%),
lesbians (43%) and bisexual men and women (49%) compared with previous
community surveys of (predominantly) heterosexual people. Meltzer et
al (1995) and Singleton
et al (2000) reported
prevalence rates of mental disorder (defined by CIS–R score) of
approximately 12% in men and 20% in women. The disparity between previous
studies and our sample suggests higher psychiatric morbidity in the gay,
lesbian and bisexual population. Alternatively, the higher rates of mental
disorder in this survey might be due to differences in recruitment methods or
biases inherent in snowball sampling (see below). Our findings suggest that
gay men and lesbians are equally likely to experience psychiatric morbidity,
in contrast to previous studies which found that women were more at risk. It
is possible that the usual gender differences are lost in our sample because
other factors, such as discrimination, are more potent causes of mental
distress in this group.

Our finding that, compared with older participants, people under 40 years
old appear to be at higher risk of mental disorder, harmful drinking and
considering self-harm contrasts with greater openness about sexuality in this
group. This might be a consequence of greater exposure to acts of
discrimination; alternatively, being open about sexuality might lead to more
assaults and insults and hence worse mental health. Another explanation is
that younger people are more likely to disclose these issues.

Limitations

The relatively small number of bisexual respondents may suggest bias
against recruiting this group to the study, although participants were invited
to participate in a ‘sexuality and well-being study’ which was
unlikely to specifically disenfranchise bisexual people. Another possible
explanation is that true bisexuality is relatively rare. Some people may
routinely identify themselves as bisexual because this is more socially
acceptable, but are more honest about their true sexuality when participating
in anonymous confidential surveys. The relatively small size of the bisexual
sample reduces power, although sufficient numbers were recruited to detect
clinically significant differences on many analyses.

It is difficult to gauge representativeness of snowball-derived samples as
there is no information on the English population of gay, lesbian and bisexual
people from which they are recruited. Snowball sampling can result in biasing
recruitment towards respondents who are willing to participate in research.
However, there are difficulties inherent in random sampling of the general
population for the purposes of our research (low prevalence of gay, lesbian
and bisexual people, high cost, and still no guarantee of unbiased samples, as
some people might not feel able to be open about their sexuality, depending on
the method of data collection). For example, Cochran et al
(2003) in a telephone and
questionnaire survey of 3032 community-dwelling adults in the USA, identified
41 gay or lesbian and 32 bisexual respondents and 115 people who refused to
answer the question about their sexuality. Therefore we believe snowballing
probably remains the best method of identifying large numbers of gay and
lesbian participants for research. A further potential limitation, inherent in
most questionnaire surveys of this type, is the absence of validation of the
responses. For example, there is no way to validate responses to questions
about attempted suicide in the absence of an association with measures such as
the CIS–R, although we feel it is unlikely large numbers of individuals
would exaggerate this issue.

Defining sexuality

Categorical self-definition of sexuality appears to equate well with other
estimates of sexuality such as gender of fantasy object, attraction and sexual
experience. Men and women who defined themselves as bisexual were less likely
than exclusively gay and lesbian respondents to report a same-sex focus for
fantasy, attraction and experience, suggesting bisexuality does merit a
separate status. This suggests that people who identified themselves as
bisexual in this study are not simply gay or lesbian and reluctant to identify
themselves as such. Although gay men and lesbians were more likely to
socialise with same-sex individuals, a large proportion of all groups
socialised with both men and women. Another finding of interest is that gay
men in particular seem to be aware of their sexuality from a young age, with
74% of the sample stating they were aware they were gay before the age of 15
years. This strongly suggests that homosexuality is innate rather than a ‘
lifestyle choice’.

Bisexuality

Although this study surveyed large numbers of gay men and lesbians, far
smaller numbers of bisexual men and women were identified, possibly because
the distribution of sexuality is bimodal and bisexuality is uncommon. A second
possibility is that we recruited fewer bisexual respondents because the study
was less relevant to them. This is unlikely, as the study was promoted as
concerning sexuality and well-being, and we were able to recruit a large
population of heterosexual respondents
(King et al, 2003).
Finally, people might have been less willing to identify themselves as
bisexual to researchers; this third possibility is suggested by our data
showing that bisexual respondents were less open about their sexuality with
family and friends and felt less comfortable about their sexuality. For
example, the parents, siblings and friends of exclusively gay or lesbian
individuals were far more likely to be aware of the respondents' sexuality
than those of bisexual respondents. Some previous studies have combined gay,
lesbian and bisexual categories for the purpose of analysis or do not report
results for bisexual groups at all (Johnson
et al, 2001; Cochran
et al, 2003). The characteristics of our bisexual
respondents suggest that they form a unique group in terms of reticence about
their sexuality. The possibility of poorer social integration may be a factor
in the increased rates of psychological distress among bisexual men. Lack of
openness about sexuality may present particular difficulties in terms of
clinical care, for example in being honest with health professionals. Our
findings also suggest that bisexual people should be treated as a separate
group for the purposes of health-related research.

Discrimination

We found high levels of perceived discrimination in the form of physical
attacks, verbal abuse, property damage and bullying at school in our sample,
and found a strong relationship between these variables and scoring above the
threshold on the CIS–R and suicidal ideation. Although it is not
possible to infer causality, because reverse causality, unidentified
confounders and reporting bias may operate here, many respondents linked
attacks with their sexuality. Caseness on the CIS–R and GHQ–12 was
not independently associated with thoughts and acts of deliberate self-harm in
this sample, but was associated with unemployment and with a history of
harassment and bullying. This suggests that schools, the police and health
professionals should take harassment due to sexuality seriously. Some
commentators have suggested that younger gay men and lesbians are less likely
to be censured about their sexuality, and may be less vulnerable to
psychological distress as a result. Our survey supports the suggestion that
younger gay and bisexual men are more open about their sexuality with family,
friends and colleagues than their older counterparts. However, this openness
does not appear to be associated with better outcomes, as younger gay, lesbian
and bisexual respondents were more at risk of exposure to acts of
discrimination or hostility, and gay men and bisexual men and women under 40
years old were at higher risk of mental disorder, harmful drinking and
deliberate self-harm than older men. Our findings support the need for
strategies that raise awareness of the vulnerability of gay, lesbian and
bisexual individuals to psychological distress and self-harm.

Clinical Implications and Limitations

CLINICAL IMPLICATIONS

Individuals defining themselves as bisexual appear to be a distinct group
meriting further research.

Most respondents reported experience of discrimination, with a high
proportion attributing it to their sexuality. These factors appear to be
linked with higher rates of mental disorder.

Considered and attempted suicide is common in gay, lesbian and bisexual
people.

LIMITATIONS

Snowball sampling may miss people who are not open about their
sexuality.

The small number of bisexual respondents increases the risk of type II
error in analysing results of this group.

We recruited too few individuals from ethnic minorities to assess the
impact of ‘double discrimination’.

Acknowledgments

We wish to thank the men and women who participated in this study. The
study was funded by the Community Fund and managed in collaboration with Mind,
the mental health charity.